=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780795997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKIN PHYSICIANS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11800 SINGLETREE LANE SUITE 205
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-829-5881
-----------------------------------------------------
Fax | 952-829-1754
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11800 SINGLETREE LANE SUITE 205
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-829-5881
-----------------------------------------------------
Fax | 952-829-1754
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SCOTT M ROSS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 952-829-5881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 1178
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------